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The rendering physician will be informed of any patients who have responded positively to the below questions. Patients with a fever of 99.7 or greater will have their appointment cancelled. They will be given information for the CDC & information to schedule a telehealth appointment.
Have you done any international travel to China, Japan, South Korea, Italy or Iran - OR - domestic travel from New York, New Jersy or Connecticut in the last 15 days?
Yes
No
Please make a selection.
If Yes, where?
Have you been in close contact with anyone that has tested positive for - OR - with a presumed positive diagnosis (quarantined) of Coronavirus (COVID-19) within the last 15 days?
Yes
No
Please make a selection.
Have you developed the following symptoms in the past 15 days?
Extreme fatigue
Cough
Shortness of breath
Fever
All non-essential guests will be asked to wait in their cars in order to limit the number of persons within an enclosed area. Guests that are deemed essential for the patient visit is subject to the same pre-appointment screening.
Essential Guests ONLY – Patient requires guest for appointment
Have you done any international travel to China, Japan, South Korea, Italy or Iran - OR - domestic travel from New York, New Jersy or Connecticut in the last 15 days?
Yes
No
Please make a selection.
If Yes, where?
Have you been in close contact with anyone that has tested positive for - OR - with a presumed positive diagnosis (quarantined) of Coronavirus (COVID-19) within the last 15 days?
Yes
No
Please make a selection.
Have you developed the following symptoms in the past 15 days?
Extreme fatigue
Cough
Shortness of breath
Fever
Submit
